10 June 2009

I joke that if it weren't for alcohol, anxiety and bad decisions we'd be out of business. I recently saw a patient for an exacerbation of her chronic pain syndrome. Despite being fairly young, she was totally debilitated and needed to use a walker. She was on massive doses of narcotics, including a fentanyl patch, methadone and percoset for breakthrough pain. Her accelerating use (and misuse) of her pain medicines had led to multiple ED visits and admissions.

When I saw her she was writhing in pain on a hallway gurney, inconsolable. I had to medicate her just to interview her, let alone perform an exam. It turned out, unsurprisingly, that she had been using her pain meds ahead of schedule and had run out of one of them. She basically wanted a refill. Unfortunately I had to inform her that it was our department policy that we don't provide refills for chronic pain medicines, as this is best managed by a primary care doc or a pain management specialist.

"But I don't have a primary care doctor," she pleaded.I was surprised. "So who has been writing your prescriptions to this point?""Dr Jones," she replied. I have known him for a long time and he's one of the better and more respected docs in the community. A stand-up guy who's famous for always being there for his patients."I think you're going to need to call Dr Jones' office in the morning to discuss your medicines," I informed her."But he's not my doctor any more! I fired him!""Why on earth did you do that?""He wasn't my advocate when I needed him to be, so I fired him. I'm through with him.""Wow," I said. "Did you really think that through? Who's going to maintain your meds?""I don't know," she wailed, "I have to find a new doctor in the next four days or I'm gonna go through withdrawal.""I'd really advise you to rethink Dr Jones. If nothing else keep seeing him until he can transition you to a new doctor.""No." Her refusal was flat and vehement. "I'm done with him. He abandoned me when I needed him."

I could not sway her, not that I tried too hard. I reviewed the office notes from Dr Jones' clinic (we share an electronic record) and I was astonished. This man had displayed the patience of Job in dealing with a very challenging personality. Dozens of phone calls, three or four per day sometimes, weekly office visits. Elaborate negotiations and agreements on narcotics, all of which had been violated by the patient, and he still kept working with her. And now he was repaid by HER firing HIM! Amazing. I never was able to figure out what perceived or imagined slight had pushed her over the edge.

Of course there was nothing I could do for her in the ER. I gave her a referral to the on call doc with a warning that he wouldn't be able to see her within four days and might well decline to write such high doses of meds for a new patient. I warned her that she would surely go through withdrawal, and while we could treat that, the ER was not going to provide her with replacement narcotics. I reminded her that all this could be avoided if she just went back to Dr Jones.

8 comments:

I bet she went back to Dr Jones. I really struggle with these kinds of patients - the ones who make really bad decisions and won't take responsibility and want me to fix it instantly. Somtimes they kind of make me crack.

Patient needs mental health referral for her probable borderline personality disorder along with treatment for her pain problem. I would not want to live her life OR deal with her crises, sad to say. It may be that Dr. Jones actually faced the patient with some consequences, so time to find a new doctor. What a sad, sad story.

Another bad decision story. I just took care of a 50 y/o woman with alcoholic cirrhosis and "fibromyalgia" who took 120 Vicodin ES in 7 days (90 grams of tylenol) because her pain was too bad. Absolutely no suicidal intent. She did Ok after a couple of days of NAC (and drank it down faster than anyone I've ever seen...yuck).

The good Dr Jones enabling of her chronic drug abuse was doing this woman no favors.

Now she has two problems. Well make that three. Chronic pain, a personality disorder and a really big monkey on her back.

Doctors have got to quit prescribing escalating doses of narcotics for these chronic pain patients. It doesn't work. They still have pain since their perception of pain is really "lack of a buzz". Or "I'm still not happy" or something similar. You can't cure a borderline personality disorder with narcs.

A patient on significant doses of methadone and a fentanyl patch probably wouldn't have much of a "buzz" by popping a few Percocets.

I wouldn't necessarily place all the blame the patient. Opioid tolerance and dependence happen even in legitimate chronic opioid use, but clearly she abusing the medications too, as she violated her "contracts" with her physician.

Perhaps Dr Jones wasn't doing her any favors by continuing to see her after she violated her opioid contract. Maybe he should have fired her.

She may benefit from seeing a pain specialist who has the courage to say that opioids aren't working for her condition and to suggest an opioid holiday, facilitated by a methadone taper. And a pain psychologist could help her set reasonable goals and expectations to become functional in the setting of chronic pain.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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